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EOO Voluntary Disclosure Form

University of Georgia

EOO Voluntary Disclosure Form

The University of Georgia is committed to the principles of equal opportunity, affirmative action, and nondiscrimination. The University requests your voluntary completion of this form, which is used to help us meet our federal compliance obligations of monitoring our recruitment, promotion, and retention processes. This information will not be used in discriminate against or to otherwise show preference to any candidate in the selection process.

Position Title

PVA Number

Candidate Information

Today's Date *

Month

Day

Year

Your Name

First

First

Last

Last

Gender *

Male

Female

How did you learn about this position?

UGA Posting

Personal Contact

Professional Journal

Print

Internet

USG Applicant Clearing House

Other

Please Identify Name of Internet or Print Publication

Voluntary Self-Identification of Protected Veteran Status

Protected veterans may have additional rights under USERRA - the Uniformed Services Employment and Reemployment Rights Act, In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service.For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.

Please check all that apply.

Veteran status

Disabled Veteran - 1) a veteran of the U.S. military, ground, naval, or air service who is entitle to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans' Affairs;, or 2) a person who was discharged or released from active duty because of a service connected disability.

Recently Separated Veteran - a veteran during the three-year period beginning on the date of such Veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.

Active Duty Wartime or Campaign badge Veteran - a veteran who served on active duty in the U.S. military, ground, navel, or air service during a time of war or in a campaign or expedition for which a campaign badge has been authorized under the laws of the administered by the Department of Defense.

Armed Forces Service Metal Veteran - a veteran who, while serving on active duty in the U.S. military, ground, navel, or air service, participated in a U.S. military operation for which an Armed Forces service metal was awarded pursuant to Executive Order 12985.

Race/Ethnicity

American Indian or Alaska Native

Asian

Black or African American

Hispanic

Multi-racial

White

Unknown

Voluntary Self-Identification of Disability

Form CC-305
OMB Control Number 250-0005
Expires 1/31/2017

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities1. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

Blindness

Deafness

Cancer

Diabetes

Epilepsy

Autism

Cerebral palsy

HIV/AIDS

Schizophrenia

Muscular dystrophy

Bipolar disorder

Major depression

Multiple sclerosis (MS)

Missing limbs or partially missing limbs

Post-traumatic stress disorder (PTSD)

Obsessive compulsive disorder

Impairments requiring the use of a wheelchair

Intellectual disability (previously called mental retardation)

Please check one of the options below:

disability

Yes, I have a disability (or previously had a disability)

No, I don't have a disability

I don't wish to answer

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform you job. Examples of reasonable accommodation include making a change to the application process or work procedures. providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

1Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

The University of Georgia is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected veteran status.

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